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Is 'legal empowerment of the poor' relevant to people with disabilities in developingcountries? An empirical and normative review.
Borg, Johan; Bergman, Anna-Karin; Östergren, Per-Olof
Published in:Global Health Action
DOI:10.3402/gha.v6i0.22854
2013
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Citation for published version (APA):Borg, J., Bergman, A-K., & Östergren, P-O. (2013). Is 'legal empowerment of the poor' relevant to people withdisabilities in developing countries? An empirical and normative review. Global Health Action, 6(22854), 1-15.https://doi.org/10.3402/gha.v6i0.22854
Total number of authors:3
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Is ‘legal empowerment of the poor’ relevant to peoplewith disabilities in developing countries? An empiricaland normative review
Johan Borg1*, Anna-Karin Bergman2 and Per-Olof Ostergren1
1Division of Social Medicine and Global Health, Lund University, Malmo, Sweden; 2Centre forSustainability Studies, Lund University, Sweden
Background: Legal empowerment of the poor is highly relevant to public health as it aims to relieve income
poverty, a main determinant of health. The Commission on Legal Empowerment of the Poor (CLEP) has
proposed legal empowerment measures in the following four domains: access to justice and the rule of law,
property, labor, and business rights. Despite being overrepresented among the poor, CLEP has not explicitly
considered the situation of people with disabilities.
Objectives: To examine the empirical evidence for the relevance of the CLEP legal empowerment measures to
people with disabilities in low- and lower middle-income countries, and to evaluate the extent to which the
Convention on the Rights of Persons with Disabilities (CRPD) addresses those measures.
Methods: Critical literature review of empirical studies and a checklist assessment of the CRPD.
Results: Fourteen included articles confirm that people with disabilities experience problems in the domains
of access to justice and the rule of law, labor rights, and business rights. No texts on property rights were
found. Evidence for the effectiveness of the proposed measures is insufficient. Overall, the CRPD fully or
partially supports two-thirds of the proposed measures (seven out of nine measures for access to justice and
the rule of law, none of the five measures for property rights, all seven measures for labor rights, and six out of
nine measures for business rights).
Conclusions: Although most of the domains of the CLEP legal empowerment measures are relevant to people
with disabilities from both empirical and normative perspectives, it is uncertain whether the devised measures
are of immediate relevance to them. Further research is warranted in this regard.
Keywords: developing country; disability; legal empowerment; low-income country; poverty
*Correspondence to: Johan Borg, Division of Social Medicine and Global Health, Lund University,
Jan Waldenstroms gata 35, SE-205 02 Malmo, Sweden, Tel: �46 70 42 42 116, Email: [email protected]
Received: 17 September 2013; Revised: 21 October 2013; Accepted: 22 October 2013; Published: 15 November 2013
Legal empowerment may be understood as the use
of law specifically to strengthen the disadvantaged
(1). Legal empowerment of the poor is highly
relevant to public health as it aims at relieving income
poverty, a main determinant of health. Considering the
links between income poverty, health, and disability in
low-income countries (2, 3), legal empowerment of the
poor may be of particular relevance to people with dis-
abilities in these countries.
Legal empowerment of the poor can be seen as a
broader tool as it also addresses other important social
determinants of health, such as improving the circum-
stances in which people live and work (4). To improve
health and health equity, the inequitable distribution of
and access to power, wealth, and social resources need
to be tackled. Unfair distribution of and access to these
means are often tolerated or promoted by social norms,
policies, and practices. Potentially, every aspect of gov-
ernment and the economy affect health and health
equity. Immediate risks for ill health, which are distrib-
uted in an inequitable way, are determined by factors at a
higher societal level, for example, the political, judicial,
and economic system, which reflects the specific power
relations of that society. Besides bringing health benefits
in the form of new technologies, goods and services, and
improved standards of living, the market place can also
generate negative conditions for health, for example,
unhealthy working conditions, environmental pollution,
and economic inequalities (5, 6).
Hosted by the United Nations Development Pro-
gramme (UNDP), the International Commission on Legal
Empowerment of the Poor (CLEP) was formed in 2005 to
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Citation: Glob Health Action 2013, 6: 22854 - http://dx.doi.org/10.3402/gha.v6i0.22854
focus on the link among exclusion, poverty, and the law.
In its final report entitled ‘Making the Law Work for
Everyone’, CLEP estimated that at least four billion
people are excluded from the rule of law (7). By giving
poor women and men access to justice, and by under-
pinning and enabling certain rights, the Report argues
that they can be empowered to change their lives for the
better. Despite poverty being the reality for many of the
world’s one billion people with disabilities (3), the Report
does not explicitly relate to them. Therefore, drawing
from available evidence, this article intends to explore the
relevance of the recommendations made by the Report
for reducing poverty � and thereby promote health �among people with disabilities living in countries where
incomes in general are low.
Legal empowermentIn the Report, legal empowerment is viewed as a pro-
cess through which poor people become protected and
are enabled to use the law to advance their rights and
their interests. It involves them realizing their rights
and reaping resulting opportunities through public sup-
port as well as efforts of themselves, their supporters, and
networks (7).
Since legal empowerment (as a political concept) was
first coined by the Asian Development Bank in the Asia
Foundation Report from 2001 (8), it has been used and
defined by a number of different institutions such as
the Carnegie Endowment for International Peace (9).
The concept gained particular momentum through the
Report, which perceives legal empowerment as a ‘global
social contract’ primarily encompassing access to justice
and the rule of law, property rights, labor rights, and
business rights (10). Property rights, labor rights, and
so-called business rights have been singled out as par-
ticular vital empowerment domains, mostly due to their
connection to economic agency; an area essential for de-
velopment in general and poverty reduction in particular.
Together with access to justice and the rule of law, these
three domains are labeled ‘pillars of legal empowerment’
(the Pillars) (7). (CLEP recognizes that ‘business rights’ is
not a human rights category per se and does not advocate
for it to be established as such, but acknowledges that this
category is ‘derived from [other] existing rights related to
doing business of the individual’ (7, p. 5).)
Legal empowerment is claimed to highlight a ‘forgotten’
dimension of poverty not covered by the Millennium
Development Goals (MDGs): that poverty is an outcome
of legal deprivation, that is, there is a lack of legal re-
cognition and protection of rights for excluded groups
(11). In this context, the primary function of legal em-
powerment of the poor is to advance ‘the process of
systemic change through which the poor and excluded
become able to use the law, the legal system and legal
services, to protect and advance their rights and interests as
citizens and economic actors’ (7, p. 3). Legal empowerment
does not consist of a single strategy, but it usually targets
disadvantaged populations, and focuses on the use of law,
the legal system and legal services in broad terms as
instruments for development, sustainable livelihood, and
poverty reduction for the disadvantaged (12).
The Pillars are based on a human rights-based ap-
proach and draws from the Universal Declaration of
Human Rights (UDHR) (13). The first pillar access to
justice and the rule of law follows from UDHR Articles 6
and 7, the second pillar property rights finds its basis in
UDHR Article 17, and the third pillar labor rights is
based on UDHR Article 23. The fourth pillar business
rights is a composite of rights of people to engage in
economic activity and market transactions. They include
the right of people to start a legally recognized business
without arbitrarily applied regulations or discrimination
in the application of norms and procedures. It focuses
on removing unnecessary barriers that limit economic
opportunities and on protecting the investments that
people make in their enterprises. Business activities are an
expression of an entire class of liberties, namely freedom
of association, freedom of movement, freedom to develop
one’s own talents, and freedom to exchange legitimately
acquired goods and services (7).
The Report acknowledges that poverty eradication
cannot be accomplished through legal empowerment
alone. However, although not sufficient in itself, legal em-
powerment is regarded as a necessary remedy for inclu-
sion economically, politically, socially, and morally (7).
Considering its recommendations being top-down, im-
practical and unrealistic, the Report has received criti-
cism (14, 15). Moreover, it has been argued that legal
empowerment of the poor needs to be linked with general
development experience, and that the Report fails to
justify its policy agenda with empirical data (16, 17).
Despite its shortcomings, it has been claimed that the
Report has contributed to the international development
community by focusing attention on legal needs of poor
populations (15).
DisabilityPeople with disabilities in low-income countries are
often deprived of basic human rights and overrepresented
among the poor (3, 18�20). Compared to those without
disabilities, they generally have lower employment rates
and educational attainment. There is a growing evidence
base that indicates substantial links among poverty,
health, and disability in these countries (2, 3).
The International Classification of Functioning, Dis-
ability and Health (ICF) intends to encompass all aspects
of human health and some health-relevant components
of well-being. It describes them in terms of health domains
and health-related domains. Examples of health domains
include seeing, hearing, walking, learning and remembering,
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while examples of health-related domains include educa-
tion, work and employment, and transportation (21).
According to the ICF, disability is understood as the
negative aspects of the dynamic interaction between an
individual’s health conditions (diseases, disorders, inju-
ries, traumas, etc.), personal factors (gender, race, age,
fitness, lifestyle, habits, social background, education,
profession, etc.) and environmental factors (elements
of the physical, social, and attitudinal environments).
Disability is used as an umbrella term for impairments,
activity limitations, and participation restrictions (21).
The environmental factors in the ICF focus on two
different levels: individual and societal. At the indi-
vidual level, the factors include physical and material
features of, and direct contacts with others in the im-
mediate environment of an individual (e.g. home, school,
and workplace). At the societal level, the factors en-
compass formal and informal social structures, services,
and overarching approaches or systems in the community
or society (e.g. organizations and services related to the
work environment, government agencies, communication
and transportation services, informal social networks,
laws, regulations, and attitudes). Society may hinder an
individual’s performance by creating barriers (e.g. in-
accessible buildings) or by not providing facilitators (e.g.
unavailability of wheelchairs, hearing aids or other assis-
tive technology) (21).
Both elimination of barriers and provision of facil-
itators may be addressed through adoption and im-
plementation of appropriate legislation, which is thus
considered an environmental factor at societal level (21).
A key example is the Convention on the Rights of
Persons with Disabilities (CRPD), which was adopted in
late 2006 to promote, protect, and ensure the enjoyment
of all human rights and fundamental freedoms by all
people with disabilities (22). Regarded as having empow-
ered the world’s largest minority, it focuses on the actions
States must take to ensure that people with disabilities
can enjoy civil, cultural, economic, political, and social
rights on an equal basis with others (22, 23).
Rights, health, and developmentLegal empowerment is a strategy to facilitate human
development through realization of a selected number of
human rights. Therefore, it has been suggested that this
approach is viewed as a subset of the broader human
rights-based approach to development and poverty
reduction (16).
Human development has increasingly been seen as
expanding economic, social, cultural, and political free-
doms rather than economic growth alone (24). Through
his capability approach, Sen connects human develop-
ment to human rights (25, 26). He suggests that human
rights can be seen as entitlements to capabilities (things
a person is substantively free to do or be) and that
expanding capabilities is development (26, 27). This
expansion can be accomplished by providing access to
such basic capabilities as healthcare, education, and the
labor market, which are all integral parts of the Pillars
(7, 28). Equity-driven development should be viewed as
a contribution to sustainability, as redistribution to the
poor in the form of improving their health, education,
and nutrition will have impacts on the current as well as
future generations (29).
It is well known that health is both a consequence of
and a factor contributing to the development of societies.
Health is thereby central to sustainable development and
its components of social, economic, and ecological sus-
tainability. Unequally distributed resources in a society
have a major impact on health and its social distribution.
Equity, therefore, appears to be a key for sustainability
defined as the survival and well-being of humans (30).
Thus, considering legal empowerment as an equalizer of
poverty alleviating opportunities, it plays a role for more
sustainable and healthier societies.
Aim and objectivesThe purpose of this study has been to contribute to ex-
panding the knowledge about strategies to reduce poverty
among people with disabilities in low- and lower middle-
income countries from a rights perspective, while keeping
in mind potential positive health and sustainability
outcomes. Considering that the CLEP recommendations
neither does explicitly address the situation of people
with disabilities in these countries nor does it relate to the
legal empowerment enshrined in the CRPD, the specific
aim was to explore the relevance of the Pillars to them.
To fulfill this aim, the objectives have been:
1) to examine the evidence base for the relevance of the
Pillars to people with disabilities in low- and lower
middle-income countries and
2) to evaluate the extent to which the CRPD addresses
the Pillars.
Consequently, the study set out to answer the following
research questions:
1) What is the empirical evidence for problems related
to the Pillars among people with disabilities in low-
and lower middle-income countries and for solu-
tions to those problems?
2) To what extent does the CRPD provide normative
support for the Pillars?
MethodsThe first research question was addressed through a
critical review and the second one through a checklist
assessment.
Legal empowerment relevant to people with disabilities
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Critical reviewTo examine the evidence base, qualitative and quantitative
research articles were searched in the following databases
on October 11, 2012: CINAHL, HeinOnline, PubMed,
SocIndex, Web of Science. Using Boolean technique, the
following combination of search terms was used in each
database: (disab* OR handic* OR impair*) AND (devel-
oping countr* OR low income countr* OR low income
econom* OR lower middle income countr* OR lower
middle income econom*) AND (legal* empower* OR
poverty OR poor OR human right* OR labour OR labor
OR employment OR work OR propert* OR rule of
law OR justice OR exclusion OR (freedom AND (produce
OR trade OR consume OR exchange))). Although health,
education, and social security issues are included in
the domains of the Pillars, such search terms were not
included in this search.
An article was included if it presents original qualita-
tive or quantitative research findings about the situation
of people with disabilities with regard to the Pillars in a
low- or lower middle-income countries, as defined by the
World Bank as of July 2012 (31), and was published in a
peer-reviewed journal in 2002 or later. Studies covering
low- or lower middle-income countries were included.
Studies in upper middle countries were included if they
also involved low- or lower middle-income countries.
Studies in upper middle-income countries only were ex-
cluded. Articles not dealing with long-term physical,
sensory, mental, or intellectual disabilities were excluded.
Without language restriction searches were performed in
titles and abstracts, in databases where such limits were
possible, or in article texts.
An overview of the process of selecting articles is given
in Fig. 1. The titles and abstracts of a total of 1,308 hits
generated by searches in the databases were screened
manually. A search record by database is presented in
Table 1. Duplicates and articles not meeting the criteria
were excluded, resulting in an initial list of 23 articles
potentially relevant to this study. The full articles in the
initial list were studied and articles not meeting all
criteria were excluded resulting in an intermediate list
of 11 articles. The reference lists were searched for any
additional research meeting the selection criteria. This
added another two articles. From the authors’ knowl-
edge, one accepted but not yet published article was
added. The selected articles in the intermediate list and
the added articles were reviewed and a data extraction
form was completed for each of them. Based on extracted
data, the authors discussed the articles and determined
that all 14 articles would be included in the final list.
Data from articles in the final list were analyzed
and the findings categorized according to four domains
corresponding to the Pillars. As the studies varied widely
in designs and methods, a complete evaluation of the
strength of the evidence was not carried out. However,
when applicable, information about sample size, study
design, and instrumentation were compiled.
Checklist assessmentIn order to evaluate the extent to which the CRPD ad-
dresses the Pillars, a checklist assessment was undertaken.
This method may be used when evaluating, for example,
health policies to know whether a policy adequately ad-
dresses various content issues and have included appro-
priate actions (32, 33). First, a checklist based on the
Database search1308 records
Initial list23 articles
12 articles excludedbased on full paper
text
Intermediate list11 articles
Final list14 articles
0 articles excludedbased on extracted
data
3 articles includedfrom reference lists
or author knowledge
1285 recordsexcluded based on
duplicates, titles andabstracts
Fig. 1. Process of selecting articles.
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measures and liberties proposed in the Report was de-
veloped. The checklist comprises 30 items in four domains,
which correspond to the four Pillars. Second, the content
of the CRPD was assessed using the checklist. The extent
to which the CRPD addresses each legal empowerment
measure was rated Addressed not at all, Addressed partly
or Addressed fully. Only specific CRPD measures were
considered. Thus, general stipulations such as ‘take all
necessary measures’ or ‘take appropriate steps’ were not
taken into account in this evaluation.
ResultsThe findings from the critical review and the checklist
assessment are presented in the following sections.
Overview of review findingsAs described above, a total of 14 articles were included in
the final list. In Table 2, the representation of economies
and regions, according to World Bank definitions, of the
reviewed articles is given. Ten of them included low-
income countries and nine included lower middle-income
countries. Articles with countries located in South Asia
and sub-Saharan Africa were most frequent (10 and 8
articles, respectively), while there were fewer articles
concerning countries from other regions.
In Table 3, an overview is given of the objectives,
designs, instruments, settings, samples, and main findings
of the studies reported in the reviewed articles. They report
the results of seven quantitative and four qualitative cross-
sectional studies, and three case studies. Five studies used
instruments based on WHO resources, two studies applied
instruments based on World Bank resources and one
study used a national survey instrument.
Column 4 of Table 4 indicates which of the 30 legal
empowerment measures are addressed by which reviewed
article.
Access to justice and the rule of lawTwo of the reviewed articles present findings related to
access to justice and the rule of law; one of them attempts
to describe the situation, while the other reports on an
intervention and its outcomes.
In a consultation with 51 people with mental and
psychosocial disabilities from 18 low- and middle-income
countries, Drew et al. (34) found that stigma and dis-
crimination lead to violations of human rights, particu-
larly denial of the right to exercise legal capacity.
Fritz et al. (35) have studied the inclusive dimension of
poverty-reduction strategy processes in three countries.
They conclude that bringing people with disabilities
into this process can be a powerful tool for improving
their situation, as it empowers people with disabilities,
develops the capacities of their organizations, and raise
awareness about their situation among government and
civil society. In Cambodia, community bodies planned
to include disability aspects in their local development
plans (35).
Property rightsNone of the reviewed articles explicitly addresses prop-
erty rights. In her qualitative study of the situation of
30 Nepalese women with physical disabilities, Dhungana
(36) noted that they were denied the right of equal inheri-
tance of property irrespective of disability status, although
disability brings discrimination one step further.
Labor rightsLabor rights issues were addressed by 13 of the reviewed
articles. Nine of them describe the situation of people
with disabilities and five of them report on various inter-
ventions intended to improve the situation. As indicated
in Table 4, 12 of the reviewed articles are concerned with
employment opportunities while two of them relate to
health.
In Nepal, Dhungana (36) found that women with
disabilities were discriminated against and excluded from
employment. Similarly, Kiani (37) reported that women
with disabilities in Cameroon had difficulty in obtaining
employment due to discrimination by employers. Also,
men with disabilities seemed to experience discrimina-
tion. Using survey data from rural India, Mitra and
Sambamoorthi (38) found that the employment rates for
men without disabilities were higher than for men with
disabilities. This difference was not explained by differ-
ences in human capital and productivity but may result
Table 1. Results of database searches
Database Records
CINAHL 37
HeinOnline 7
PubMed 339
SocIndex 32
Web of Science 893
Table 2. Representation of economies and regions
World Bank economies and regions No. of articles
Low income 10
Lower middle-income 9
Upper middle-income 3
East Asia and Pacific 3
Europe and Central Asia 1
Latin America and Caribbean 2
Middle East and North Africa 1
South Asia 10
Sub-Saharan Africa 8
Legal empowerment relevant to people with disabilities
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from discrimination in access to employment and from
differential returns to characteristics (38). The situation
of men has also been studied in Bangladesh. With an
objective to examine the impact of disability on the
quality of life, Hosain et al. (39) conducted a survey and
identified 162 Bangladeshis with disabilities. Nearly 80%
of the men above 12 years of age reported that disability
had some negative consequence on their employment, for
example, lower salary than non-disabled, forced to
change employment and unemployment (39).
These findings are supported by further studies. A
comparison of the situations in 15 developing countries
by Mitra et al. (40) found that people with disabilities
were employed to a statistically significantly less degree
than people without disabilities in nine countries.
In Afghanistan and Zambia, Trani and Loeb (28) found
that people with disabilities had lower access to the labor
market. People with cognitive, mental or multiple dis-
abilities were the least likely to work (28). Moreover, from
a study in India, Uppal and Sarma (41) reported that
disabilities and chronic illnesses have a negative associa-
tion with the probability of working, the effect being
stronger in rural areas.
The status of people with mental and psychosocial
disabilities has been studied by Drew et al. (34). They
found that denial or restriction of employment rights
and opportunities was the second most common rights
violation (after ‘exclusion, marginalization, and dis-
crimination in the community’), and the workplace or
potential workplace was the third most likely environ-
ment in which human rights violations take place (after
‘general community setting in everyday life’ and ‘home
and family settings’). More than 60% of the respondents
said that their ability to find or maintain a job was ad-
versely affected by their mental or psychosocial disability
(34). Similarly, from a comparison of the situations of
people without impairments and people with musculos-
keletal impairments (MSIs) in Rwanda, Rischewski et al.
(42) reported that the latter group was less likely to be
employed.
People with disabilities in Afghanistan and Zambia
tended to have less access to healthcare services (28).
After these descriptions of the situations of people with
disabilities with regard to labor rights, interventions that
intend to address the problems in this domain are
presented in the following.
Fritz et al. (35) report that as a result of an inclusive
poverty-reduction strategy process in Cambodia, con-
tacts were established between community councils and
organizations and groups of people with disabilities.
These councils then took certain actions, including certi-
fication of people with disabilities as poor citizens with
free access to health centers, and messages to reduce
discrimination against people with disabilities and en-
courage them to participate in socio-economic activities.
Cooperation mechanisms were established between offi-
cial stakeholders and organizations of people with
disabilities. Creating sustainable structures of empower-
ment was found to be crucial (35).
In Nepal, Dhungana (36) found that women got less
access to vocational training programs than men. Men
got training in skills that are in high demand and which
command good salaries, while women were trained in
skills they would not be able to use in their villages, which
consequently prevented them from returning home to
work (36). This finding is supported by a case study of a
community-based vocational rehabilitation (CBVR) pro-
gram for people with disabilities carried out by Alade (43)
in Nigeria. She found that 90% of 155 participants had
been gainfully employed. Four features of the program
were: an orientation toward skills required locally; a
preference for non-formal short-cycle program; a reliance
on local markets and resources; and promotion of local
participation in planning and implementation (43).
Presenting case studies of corporate social responsi-
bility projects in Bangladesh, Werner (44) notes that one
of them targeted women with disabilities and that it
increased their employment opportunities by improving
their job skills.
In a study of 583 people with hearing or ambulatory
impairments in Bangladesh, Borg et al. (45) found that
the use of assistive technology was associated with certain
labor rights. Compared to people with hearing impair-
ments who did not use hearing aids, users of hearing aids
were more likely to report better access to medical care,
better physical and mental health, and higher participa-
tion in work. However, working status did not differ
significantly between users and non-users of hearing aids.
In the ambulatory group, people using wheelchairs were
less likely to work compared to people not using wheel-
chairs. After adjusting for the level of physical accessi-
bility to the working place, there were no significant
differences in work status between these groups. However,
wheelchair users reported a higher level of participation
in work. Among wheelchair users alone, it was found that
those who had used their wheelchair for a longer period
of time were more likely to work (45).
Business rightsEleven reviewed articles addressed issues related to
business rights. The situation of people with disabilities
with regard to these rights is described in eight of them,
while measures to overcome related problems are ad-
dressed by four articles. Nine articles are concerned with
issues of developing one’s own talents and four articles
address freedom of movement.
Opportunities to develop one’s own talents through
education are lacking for people with disabilities in many
countries. In 14 out of the 15 countries studied by Mitra
et al. (40), people with disabilities had completed primary
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Table 3. Overview of included articles
First author, year,
and reference Objective
Study design, instrument,
and setting Sample Main findings
Alade 2004 (43) To describe a community-based
vocational rehabilitation (CBVR)
program and its outcomes.
Case study. Nigeria. A CBVR program with a total of
155 participants with various
disabilities over 8 years.
More than 90% of the participants were gainfully
employed. About 10% of the trainees had benefited from
a revolving loan scheme.
Borg 2012 (45) To explore the relation between
assistive technology use and
enjoyment of human rights.
Quantitative cross-sectional.
Questionnaire based on ICF.
Bangladesh.
Hearing impairment: 136 people
using hearing aids, 149 not
using hearing aids. Ambulatory
impairment: 149 people using
wheelchairs, 149 people not
using wheelchair.
Hearing aid use was positively associated with access to
medical care, physical, and mental health, literacy,
education, participation in school, participation in work,
participation in using public transportation, and ambulatory
performance. Working status did not differ statistically
significantly between users and non-users of hearing aids.
Wheelchair use was statistically significantly associated
with better ambulatory performance and lower likelihood of
working. Physical accessibility to working places and
duration of wheelchair use was statistically significantly
associated with higher participation in work and positive
work status, respectively.
Dhungana
2006 (36)
To explore and discuss the lives
of women with disabilities and
analyze how external factors put
these women at the lowest level
of existence.
Qualitative cross-sectional
(interview). Nepal.
30 women with physical
disabilities.
Women had no or little education, were discriminated
against when it comes to jobs and were excluded from
employment. Women got less advantage of vocational
training programs for people with disabilities. Men got
training on skills in high demand. The built environment is
not accessible. Inaccessible buildings, including toilets,
make it impossible to keep a job or to look for training and
jobs. Public transportation services were inaccessible.
(Women are denied equal inheritance of property.)
Drew 2011 (34) To review the evidence for the
types of human rights violations
experienced by people with
mental and social disabilities in
low-income and middle-income
countries as well as strategies
to prevent these violations and
promote human rights.
Qualitative cross-sectional
(questionnaire, literature review).
Questionnaire partly based on
WHO Quality Rights Assessment
Tool. Belize, Bosnia and
Herzegovina, Egypt, Georgia,
Ghana, Indonesia, Jordan, Kenya,
Lithuania, Mexico, Nepal,
Paraguay, Peru, South Africa,
Sri Lanka, Tajikistan, West Bank
and Gaza, Zambia.
51 people with mental and
psychosocial disabilities.
Literature in English (UN
publications, non-governmental
organization reports, press
reports, academic literature)
Stigma and discrimination lead to violations of human
rights, including civil, cultural, economic, political, and
social rights. Denial of people’s rights to exercise legal
capacity and discrimination in employment are central
issues.
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First author, year,
and reference Objective
Study design, instrument,
and setting Sample Main findings
Fritz 2009 (35) To examine the inclusive
dimension of poverty-reduction
strategy (PRS) processes, to
review the relationship between
poverty and disability in three
projects, to describe the three
projects and to analyze their
successes and challenges.
Case studies. Cambodia,
Tanzania, Vietnam.
3 PRS projects The PRS process provides a framework for capacity
development of disabled peoples’ organizations and for
raising awareness on disabilities among government and
civil society. The public and authorities perceived people
with disabilities differently and acknowledged their rights
and needs. In Cambodia, community bodies signalled that
they plan to include disability aspects in their development
plans and people with disabilities were called to participate
in vocational training programs. It is important to create
sustainable structures of empowerment.
Hosain 2002 (39) To examine the impact of
disability on the quality of life
of people with disabilities.
Quantitative cross-sectional.
ICF, SF-36. Bangladesh.
162 people with disabilities More than 70% of 57 respondents aged 5�30 years had
been unable to attend or compelled to leave school due to
disability. About four out of five men aged above 12
responded that disability had negative consequence on
their employment, including lower salary than non-disabled,
forced to change employment or being unemployed.
Kiani 2009 (37) To analyze the gap in current
and desired life situations of
women with disabilities.
Qualitative cross-sectional
(focus groups, interviews and
participant observation).
Cameroon.
Focus groups: 24 (15�9)
Interviews: 12
Difficulty in obtaining employment due to discrimination by
employers or lack of education. Difficult to move around
and reach markets, workplaces, etc. No public or
accessible transportation system. Negative attitudes when
attempting to use taxi or using the road. Desire to learn
income-generating skills and entrepreneurships. Need for
capital to run and maintain businesses.
Mitra 2008 (38) To explain employment
differences between males
with and without disabilities.
Quantitative cross-sectional.
World Bank Village Disability
Survey. India.
262 men with disabilities, 980
men without disabilities.
The employment rate for men without disabilities was
higher than for men with disabilities. The gap was not
explained by differences in human capital and productivity.
It may result from differential returns to characteristics and
from discrimination.
Mitra 2013 (40) To draw an economic profile of
persons with disabilities.
Quantitative cross-sectional.
World Health Survey.
Bangladesh, Brazil, Burkina Faso,
Dominican Republic, Ghana,
Kenya, Lao PDR, Malawi,
Mauritius, Mexico, Pakistan,
Paraguay, Philippines, Zambia,
Zimbabwe.
All countries together: 7,443
persons with disabilities, 84,381
persons without disabilities.
In 14 countries, people with disabilities had completed
primary school to a statistically significantly less degree
than people without disabilities. In 9 countries, people with
disabilities were employed to a statistically significantly less
degree than people without disabilities.
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First author, year,
and reference Objective
Study design, instrument,
and setting Sample Main findings
Rischewski
2008 (42)
To assess the association
between poverty and
musculoskeletal impairment
(MSI).
Quantitative cross-sectional.
Questionnaire based on World
Bank’s Living Standards
Measurement Study. Rwanda.
345 persons with MSI, 532
controls
Adults with MSI were more likely to have no employment.
Children with MSI were less likely to attend school.
Savill 2003 (46) To identify barriers experienced
by people with disabilities when
using public transport services in
urban areas of the developing
world.
Qualitative cross-sectional
(interview, focus groups). India,
Malawi, Mozambique,
South Africa.
Up to 150 people with disabilities
in each country.
Three types of barriers to accessibility were identified:
structural, social, and psychological.
Trani 2012 (28) To compare data collected from
household surveys and to explore
the potential link between
multidimensional poverty and
disability.
Quantitative cross-sectional.
Questionnaire partly based on
ICF. Afghanistan, Zambia.
Afghanistan: 641 persons with
disabilities, 903 controls. Zambia:
1,845 persons with disabilities,
1,643 controls.
People with disabilities have lower access to education and
labor market. To some extent they also have less access to
healthcare services. Women with disabilities had a very low
likelihood to have had access to school. Persons with
cognitive, mental or multiple disabilities were the least likely
to work.
Uppal 2007 (41) To explore the relationship
between the health status of
the elderly and their labor
market participation.
Quantitative cross-sectional.
1995/96 National Sample Survey.
India.
32,338 aged 60 years and above,
nationally representative
Disabilities and chronic illnesses have a negative
association with the probability of working, the effect
being stronger in rural areas.
Werner 2009 (44) To present corporate social
responsibility (CSR) projects
that are designed to reduce social
exclusion among marginalized
populations and to explore
whether CSR initiatives can
increase economic and social
capabilities to reduce exclusion.
Case studies (interviews,
literature). Bangladesh.
Purposive selection of CSR
examples, including one
targeting, among others, women
with disabilities.
One example of the CSR initiatives increases job skills and
employment opportunities for women with disabilities.
More than 80 out of 1,800 women have a disability.
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Table 4. What legal empowerment measures of the CLEP pillars are addressed by which CRPD articles and reviewed articles.
CRPD articles addressing
the measure1
Reviewed articles addressing
the measureLegal empowerment measures Fully Partly
Domain: access to justice and the rule of law (7, pp. 5�6)
1. Ensure that every person with disability has the right to legal identity and is registered at birth. 12(1�2);
18(2)
(34)2
2. Repeal or modify laws and regulations that are biased against the rights, interests, and livelihoods of people with
disabilities.
4(1.a�c,e) (34, 35)
3. Facilitate the creation of state and civil society organizations and coalitions, including paralegals who work in the interest of
people with disabilities.
4(3); 33(1, 3) (35)
4. Establish a legitimate state monopoly on the means of coercion, through, for example, effective and impartial policing. 14(1.b, 2);
15(2); 16(4)
5. Recognize and integrate customary and informal legal procedures with which people with disabilities are already familiar
(regarding the formal judicial system, land administration systems and relevant public institutions).
6. Encourage courts to give due consideration to the interests of people with disabilities. 13
7. Support mechanisms for alternative dispute resolution.
8. Foster and institutionalize access to legal services so that people with disabilities will know about laws and be able to take
advantage of them.
12(3); 13;
16(2)
9. Support concrete measures for the legal empowerment of women, minorities, refugees, internally displaced persons and
indigenous people with disabilities.
6(2)
Domain: property rights (7, p. 7)
10. Promote efficient governance of individual and collective property in order to integrate the extralegal economy into the
formal economy and ensure it remains easily accessible to people with disabilities.
11. Ensure that all property recognized in each nation is legally enforceable by law and that all owners with disabilities have
access to the same rights and standards.
(36)2
12. Create a functioning market for the exchange of assets that is accessible, transparent, and accountable.
13. Broaden the availability of property rights, including tenure security, through social and other public policies, such as
access to housing, low interest loans and the distribution of state land.
(36)2
14. Promote an inclusive property rights system that will automatically recognize real and immoveable property bought by
men as the co-property of their wives or common-law partners.
(36)2
Domain: labor rights (7, pp. 7�8)
15. Respect, promote, and realize freedom of association so that the identity, voice, and representation of the working people
with disabilities can be strengthened in the social and political dialog about reform and its design.
27(1.c);
29(b)
16. Improve the quality of labor regulation and the functioning of labor market institutions, thereby creating synergy between
the protection and productivity of people with disabilities.
27
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Table 4 (Continued)
CRPD articles addressing
the measure1
Reviewed articles addressing
the measureLegal empowerment measures Fully Partly
17. Ensure effective enforcement of a minimum package of labor rights for workers with disabilities and enterprises in the
informal economy that upholds and goes beyond the Declaration of Fundamental Principles and Rights at Work.
273
18. Increase access to employment opportunities for people with disabilities in the growing and more inclusive market
economy.
27 (28, 34�45)
19. Expand social protection for workers with disabilities in the event of economic shocks and structural changes. 27(1.e); 28(2)
20. Promote measures that guarantee access to medical care, health insurance and pensions for people with disabilities. 25; 26;
28(2.e)
(28, 45)
21. Ensure that legal empowerment drives gender equality among people with disabilities. 6(2)
Domain: business rights (7, pp. 8�9, 31)
22. Guarantee basic business rights for people with disabilities; including the right to vend, to have a workspace, and to have
access to necessary infrastructure and services (shelter, electricity, water, sanitation).
26(1.b); 27(f)
23. Strengthen effective economic governance that makes it easy and affordable for people with disabilities to set up and
operate a business, to access markets and to exit a business if necessary.
19(b); 26(1.b);
27(f)
24. Expand the definition of ‘legal person’ to include legal liability companies that allow owners to separate their business and
personal assets, thus enabling prudent risk taking.
25. Promote inclusive financial services that offer entrepreneurs with disabilities savings, credit, insurance, pensions and
other tools for risk management.
19(c); 27(1.f) (37, 43)
26. Expand access to new business opportunities through specialized programs to familiarize entrepreneurs with disabilities
with new markets and help them comply with regulations and requirements, and that support backward and forward
linkages between larger and smaller firms.
(43)
27. Ensure freedom of association of people with disabilities. 27(1.c); 29(b)
28. Ensure freedom of movement of people with disabilities. 18(1); 20 (36, 37, 45, 46)
29. Ensure freedom of people with disabilities to develop one’s owns talents. 30(2) (28, 35�37, 39, 40, 42, 44, 45)
30. Ensure freedom of people with disabilities to exchange legitimately acquired goods and services.
1Numbers in brackets refer to specific sections of the mentioned CRPD article.2The reviewed article addresses the measure to a limited extent.3CRPD does address labor rights for workers with disabilities but not explicitly for enterprises in the informal economy.
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school to a significantly less degree than people without
disabilities. From Afghanistan and Zambia, Trani and
Loeb (28) reported that people with disabilities have
lower access to education, particularly women. Similarly,
women with disabilities in Nepal reported little or no
education, and, as mentioned above, they also got less
from the vocational training that they received (36). In
their study in Bangladesh, Hosain et al. (39) found that
41 out of 57 respondents aged 5�30 years had been unable
to attend school due to disability or were compelled to
leave school (39). Also, Rischewski et al. (42) found that
children with MSIs were less likely to attend school. In
the North West province of Cameroon, women with
disabilities had difficulties in obtaining employment
due to lack of education. However, they desired to learn
income-generating skills and entrepreneurships and
expressed a need for capital to run and maintain
businesses (37).
Freedom of movement is limited for people with dis-
abilities. In Nepal, inaccessible transportation services,
buildings, and toilets as well as the lack of ramps in public
areas were identified as major obstacles to freedom of
movement, which in turn prevented them from looking
for training and jobs and sometimes keeping a job (36).
In Cameroon, women with disabilities found it difficult
to move around and reach markets, workplaces, and
so on, partly because there was no public or accessible
transportation system. In addition, they faced negative
attitudes when attempting to use taxis or when using the
road (37). Savill et al. (46) identified three types of
barriers experienced by people with disabilities when
using public transport services in urban areas of four
countries, namely structural, social, and psychological
barriers.
After these descriptions, measures intended to improve
the enjoyment of business rights are reported below.
Following an inclusive poverty-reduction process in
Cambodia, commune councils called for people with
disabilities to participate in vocational training programs
(35). As already mentioned above, one of the corporate
social responsibility projects in Bangladesh increased job
skills for women with disabilities, which led to better
employment opportunities (44). The CBVR program in
Nigeria included a revolving loan scheme enabling 15
trainees to purchase equipment and materials for their
trades. Due to the general breakdown of the country’s
economy, most of the beneficiaries experienced difficul-
ties in making regular installments to pay back the loan,
which hampered the revolving loan scheme and deprived
others from its benefit (43).
The study of Borg et al. (45) in Bangladesh reported
that users of hearing aids were more likely to report
literacy, higher education and higher participation in
school than non-users with hearing impairments. They
were also more likely to report higher participation in
using public transportation and better ambulatory per-
formance. In the ambulatory group, wheelchair use was
associated with better ambulatory performance. There
was also a positive relation between physical accessibility
and level of participation in work (45).
Checklist assessmentThe extent to which the CRPD addresses the Pillars is
summarized in Table 4. The checklist indicates which
articles (or parts of articles) of the CRPD address which
legal empowerment measure and to what extent. Mea-
sures lacking article numbers in their rows were not
addressed at all by the CRPD.
Regarding the nine legal empowerment measures for
access to justice and the rule of law, the CRPD addresses
four measures fully, three partly and two not at all. The
CRPD does not address any of the five empowerment
measures related to property rights. Four out of seven
legal empowerment measures related to labor rights are
addressed fully and three partly. Finally, out of nine legal
empowerment measures related to business rights, two
are addressed fully, four partly and three not at all. In
summary, 10 out of 30 empowerment measures recom-
mended by the Report are fully addressed by the CRPD,
10 partly addressed, and 10 not addressed at all.
Discussion
Discussion of findingsLegal empowerment is considered to be a process through
which poor people become protected and are enabled to
use the law to advance their rights and their interests.
This study has explored the empirical and normative re-
levance of the four CLEP Pillars to people with disabili-
ties in low- and lower middle-income countries.
With the exception for property rights, the reviewed
articles offer relatively consistent evidence for people with
disabilities in low- and lower middle-income countries ex-
periencing problems related to the Pillars, even though
not all subdomains were covered. Thus, the empirical
findings indicate that several � if not all � problems ad-
dressed by the Pillars are relevant to this population.
However, it is not possible to determine whether the
suggested solutions are relevant, as the reviewed articles
provide insufficient evidence for the effects of the re-
commended legal empowerment measures.
The assessment of the CRPD revealed that two-thirds
of the legal empowerment measures put forward in the
Report are required by the CRPD to promote, protect,
and ensure the enjoyment of all human rights and
fundamental freedoms, although only one third of the
measures are fully supported by the CRPD. Given the
support for a majority of the measures, all of the Pillars
except property rights are considered to be normatively
relevant.
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Suggested legal empowerment measures to address
access to justice and the rule of law are relatively well
supported by the CRPD. However, the CRPD does not
provide explicit support for the use of customary, in-
formal or alternative legal procedures to improve access
to justice and the rule of law. Only two empirical studies
related to this domain were found, indicating that it is an
under-researched area.
Besides lacking normative support from the CRPD,
property rights issues for people with disabilities in low-
and lower-middle income countries seem to be almost
unexplored. Neither explicit descriptions of the situation
nor possible intervention measures were found in the
reviewed literature. Considering property rights being
one of the Pillars, the lack of normative support and
empirical evidence was unexpected. However, this may
partly be explained by the lack of explicit property-
related terms used in the search. Another reason may be
that property rights is a complex matter. It is not obvious
that private ownership is always better than other
alternatives. For example, the benefits of private owner-
ship of land over open-access depend on several factors,
such as population density, dangers, and costs for en-
closure. Under certain conditions, which take into con-
sideration factors such as production level, returns from
investments and economies of scale, a communal prop-
erty system may be more beneficial than an individual
property system. Moreover, recent findings indicate that
those who possess at least the rights of proprietorship � if
not full ownership � are able to govern and manage their
systems more effectively than previously presumed (47).
Another property aspect likely to be of immediate
relevance to people with disabilities in low-income coun-
tries, as they often belong to the most marginalized group
of society, is land grabs of various scales. Although land
grabs can have a positive impact on local communities,
findings from sub-Saharan Africa indicate that the results
are more often negative (48). Considering the links among
poverty, health, and disability (2), land grabbing is likely
to significantly affect the lives of people with disabilities if
they are forced to leave their source of food or income
without adequate long-term compensation. No literature
addressing this aspect has been found, indicating an im-
mediate need to pay attention to land grab experiences
and effects among this vulnerable population.
All suggested legal empowerment measures in the
domain of labor rights are addressed by the CRPD.
This domain also had the largest body of empirical
findings describing the situation of people with disabilities
and possible interventions. However, with few exceptions,
the identified literature addressed employment and
work only. The limited number of articles on health and
healthcare may be explained by not including health terms
in the search. The reason being that they are probably
among the most studied areas with respect to people with
disabilities (see e.g. Ref. 3). None of the studies on labor
rights were longitudinal.
Most of the legal empowerment measures to support
business rights find some normative support in the
CRPD, although it is not always as specific. Identified
empirical evidence is mainly concerned with education,
vocational training, and skills development. Only a few
studies attempt to describe the effects of related inter-
ventions. There are some studies describing barriers to
limitations in enjoying the freedom of movement, while
only one study of a possible facilitator was identified.
However, it is not a longitudinal study.
Based on this review, certain legal empowerment mea-
sures recommended by the Report are supported empiri-
cally and normatively. However, the suggested measures
go beyond both what the CRPD requires and what is
supported by the identified evidence base. The Report has
previously been criticized for lack of clarity and unsub-
stantiated claims (16). Therefore, it remains to be seen if
its suggested measures for reducing poverty hold true for
people with disabilities in low- and lower middle-income
countries, or if other factors will continue to be more
important causes of poverty. In addition to general causal
factors, the opportunities for poverty reduction may be
limited due to more immediate factors, such as stigma,
and lack of access to rehabilitation services, assistive
technology, and physically and cognitively accessible
facilities (3, 49).
Although the CRPD is regarded as having empowered
the world’s largest minority (23), the recommendations of
the Report suggests that implementing only the CRPD
would not be sufficient to reduce poverty for this group.
In fact, Drew et al. (34) argue that, besides adopting and
applying the framework of the CRPD, using a range
of evidence-based strategies can help to promote human
rights. Although no firm evidence was found through this
review, complementing the CRPD measures with legal
empowerment measures recommended in the Report may
be considered.
Concerning people with disabilities in low- and lower
middle-income countries, there appears to be a lack of
evidence with respect to their poverty situation and
appropriate poverty-reduction strategies. In addition to
the findings presented in this review, a recent critical review
of the links among disability, poverty, and health con-
cluded that the evidence is strikingly thin (2). Considering
the current empirical evidence for the Pillars and recom-
mended empowerment measures found through this
literature review, the findings warrant research that
clarifies whether all domains are relevant to people with
disabilities and explores the effectiveness of suggested and
other measures. Recognizing that countries differ geogra-
phically, culturally, socially, politically, and so on, stu-
dies in various settings are called for. This would be helpful
in informing the development and implementation of
Legal empowerment relevant to people with disabilities
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effective strategies aiming at reducing poverty among
people with disabilities in low- and lower middle-income
countries, and thereby contribute to sustainable and
healthier societies (30).
Discussion of limitationsThe critical review is limited in scope to the databases,
search terms and the inclusion and exclusion criteria used.
Although the labor and business rights domains of the
Pillars include measures related to health conditions and
care, social security, and talent development (education),
search terms for these measures were not used as they have
been studied and reported elsewhere (2, 3, 50�52).
The domains of legal empowerment measures are
somewhat overlapping, for example, measures 15 and
27 on freedom of association, which could have caused
problems in categorizing articles. But as no reviewed
articles addressed freedom of association, such problems
did not arise.
It may be argued that certain legal empowerment mea-
sures are relevant to domains other than those indicated
in Table 4. For example, ensuring freedom of movement
is likely to be relevant to labor rights and its measure of
access to medical care. However, the operationalization
of the Pillars followed the measures devised by the
Report.
Due to its inclusion criteria, the review has neither
considered publications of related international organiza-
tions such as the Global Applied Disability Research and
Information Network on Employment and Training
(GLADNET), the International Labour Organization
and the World Bank, nor has UN country reports been
considered.
ConclusionsThe CRPD lends support to a majority of the legal em-
powerment measures recommended by the Report, which
indicates that most of them are relevant from a normative
perspective. Considering that the empirical evidence
demonstrates that several problems related to the Pillars
are experienced by people with disabilities in low- and
lower middle-income countries, and that little has been
published on solutions to these problems, it may be
concluded that the problem areas are relevant while it is
uncertain whether the devised measures are of immediate
relevance to this population. Further research is required
to explore the costs and effects of the proposed measures
for reducing poverty and consequently promoting health,
particularly in comparison with measures devised by the
CRPD. The lack of normative and empirical perspectives
on property rights calls for studies of their relevance.
Conflict of interest and funding
This study was funded by the Lund University Initiative
on Legal Empowerment of the Poor.
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Legal empowerment relevant to people with disabilities
Citation: Glob Health Action 2013, 6: 22854 - http://dx.doi.org/10.3402/gha.v6i0.22854 15(page number not for citation purpose)
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